19, Jun 2021 | CJP Team
The pandemic, while bringing on a sea of tragedies for Indians, has exposed the unpreparedness of callous governments which left people to the mercy of an over-burdened and structurally weak healthcare system. While the enormity of the second wave of Covid in India caught the central as well as state governments off guard.
Some states, depending on myriad factors, have fared relatively better than the worse off states like Uttar Pradesh and Bihar, but didn’t quite match up to Kerala, Tamil Nadu or Odisha. These moderately performing states have battled with weak public health systems, made worse by privatisation of health care, a higher surge of cases or even a poorer state economy to stay afloat in this crisis while avoiding a major health crisis of deaths caused due to lack of basic health facilities.
Federalism and power play
The myopic, even authoritarian attitude of the Central government in 2020, taking decisions unilaterally without consulting state governments has made matters worse. Under the Constitution, health is a state subject, and it is for states to build their own capacities and healthcare systems as they deem fit. However, at times of crises, in the true spirit of federalism, under the National Disaster Management Act, 2005, consultation and coordination are key. This has been woefully lacking.
While putting the onus entirely upon the states in terms of handling the Covid-19 Pandemic is not entirely correct legally speaking, it remains crucial to examine the role played by state governments and how some states have fared better in managing the covid situation and how some have fared moderately well. There are certainly many factors involved here including building of a robust public healthcare system over the years: building capacity, augmenting and retaining human resources especially medical professionals, maintaining optimum levels of bed to population and doctor to population ratio as also real time management of crisis by administration under the leadership of an able government. More than anything else, making good, efficient and affordable healthcare accessible to the maximum number of Indians, in the most remote areas, is fundamental to democratising the right to health.
While some states have seen the worst of this Covid crisis, few other states have managed to stay afloat while few others have managed to somehow sail through this on-going crisis. These can be called the states that have performed moderately well during this crisis and while they were not able to put their best foot forward, they managed to not sink to the worst position.
Maharashtra, ever since the pandemic escalated in 2020, has been the state with the highest number of cases. The state has seen 58.8 lakh cases and over 1 lakh deaths as of June 9.
A central government team that visited 30 districts of Maharashtra in March-April 2021 found that testing capacity has been overwhelmed in six districts, oxygen supply is an issue in four and healthcare staff is in short supply in seven districts affecting services like monitoring of patients at home. The state – which alone accounts for 48.57 per cent of the total active caseload of the country – was also found to have “sub-optimal” containment operations in several districts. The testing capacity in several districts in the state is overwhelmed, resulting in a delay in reporting test results. This was when the state was still under weekend lockdown in early April.
Seen as ‘medical hubs’ for both the country and the state, Mumbai and Pune have seen significant change in their healthcare systems since independence, characterised by: increasing pressures on an under-resourced public healthcare system; the emergence of small-sized and medium-sized private hospitals and, most recently, corporatisation trends involving growth of corporate hospitals, partnering of not-for-profit hospitals with management companies and erosion of the small-sized private hospitals.
Simultaneously, there has been a chronic neglect of public health care in the state as private health care kept mushrooming across districts. The state’s annual health budget for 2020-21 (4.3% of its expenditure) has been lower than the average allocation for health by the other states (5.3%).
For 2020-21, the Maharashtra government planned to spend Rs 1,350 per person on health while there are smaller states like Goa (Rs. 6,091) and Himachal Pradesh (Rs. 3,768) that spend a lot more per capita on health.
The most unfortunate incidents that exposed the absence of safety care and monitoring were the incidents that took place at Nashik where oxygen system malfunction in a Covid hospital caused 22 deaths on April 21, 2021, a fire in a Thane hospital, a non-Covid facility, caused 4 deaths on April 28, 2021, 14 deaths in a hospital fire in Virar on April 23, 2021, 9 deaths in a Mumbai hospital due to fire on March 26, 2021, and deaths of 10 infants in Bhandara district Hospital on January 9, 2021. These are the deaths by negligence caused in Maharashtra this year alone.
While these are important data points in comprehending how the state’s response has been, it is also important to look at the measures taken at the start of the pandemic in March-April 2020. One of its initial responses included issuing a directive on May 21, 2020, directing charitable hospitals that 80% if their operational bed capacity will be regulated by rates decided by the government. This was a decent welfare measure. How will this translate into more accessible healthcare in non-pandemic times?
Maharashtra witnessed its first Covid-19 case on March 9, 2020 and within three days, on March 13, with nearly 15 positive cases, Maharashtra’s chief minister Uddhav Thackeray during the state legislative assembly declared the Covid-19 outbreak as an epidemic and invoked the Epidemic Diseases Act, 1897 in five cities: Mumbai, Navi Mumbai, Nagpur, Pune and Pimpri Chinchwad. The government soon started preparing to equip testing and treatment facilities to manage the epidemic. With only three testing facilities in March, by the first week of April, by roping in the private sector, it managed to reach close to 15 laboratories in total.
Further, as cases of overcharging by private hospitals became widespread and rampant, a notification was issued to cap prices of medical procedures in all private and charitable hospitals under the preferred provider network. This was an important move for a state where private sector has taken over health care in most parts. While this is a temporary move, it could pave the way for regulation of prices in the future.
Further, Mumbai’s high population density of 20,634 per square kilometre challenged all norms of social distancing. This issue was addressed with the help of the municipal corporations by identifying and converting unoccupied but constructed buildings into isolation centers for mildly symptomatic or asymptomatic patients. Maharashtra has 18 government medical colleges with 500 ventilators; this was increased by three times to more than thirteen hundred in a span of six months.
The governments are paying attention to healthcare now due to the pandemic however, there are many other ailments that people suffer from that need medical attention amidst the pandemic, what about them? In an article in The Leaflet, Ravi Duggal, a health budgetary activist, brought attention to this issue and pointed out that routine ailments have seen drastic declines in access and use. He highlighted that in Maharashtra, compared to last year, in-patient admissions saw a decline of about 43% while minor operation saw a decline of 54%. Further public institutional deliveries also saw a decline of about 21%.
According to a June 2020 report by The Centre for Disease Dynamics, Economics & Policy, Maharashtra has 1.72 beds per 1,000 population or 17.2 beds per 10,000 population with 0.38 public hospital beds per 1,000 population.
Chhattisgarh has seen about 9.8 lakh cases and over 13,000 deaths as of June 9.
Chhattisgarh became the first state in India to provide medical insurance to the tune of Rs. 50,000 for all citizens with the Mukhyamantri Swasthya Beema Yojana. As of 2018, it has 793 PHCs and 5,186 Secondary Healthcare Facilities. As per the Census 2011 data, about 77% of total population lives in rural areas. Chhattisgarh is the country’s poorest state with around 40 per cent people below the poverty line.
In 2011–2012, as per the estimates of the National Sample Survey Organization, consumer expenditure survey 68th round, in Chhattisgarh, the share of expenditure on medicines out of overall household expenditure on health stood at 70.1%. For the state, one of the key challenges identified was improving the access and reducing out of program experience by ensuring the availability of free generic medicines. Thus, in 2011, the state government set ups the Chhattisgarh Medical Services Corporation Limited (CMSCL) for centralized procurement of drugs, improves supply chain management, and prevents stock-outs and expiry of medicines. The state has come a long way and has made considerable progress in increasing access to generic medicine.
The state has also applied the Public-Private Partnership (PPP) model in their health care sector. A 2018 report in Scroll states that the state had invited bids to build and manage six 100-bed hospitals and to run pathology, X-ray and CT scan services in government hospitals. In these hospitals, 20% of patients in the out-patient department and 40% of admitted patients would have to be provided free services. However, the article highlights how this model of “Build Own Operate and Transfer”, or BOOT, model has failed in the past not only in this state but in other states as well. It cites the example of a public-private partnership in which free land was given to Vedanta Cancer Hospital failed as the hospital did not adhere to the contract. Other instances include the Rajiv Gandhi Super-Speciality Hospital in Karnataka’s Raichur district, primary health centres in the same state, community health centres in Uttarakhand, Seven Hills Hospital in Mumbai, and two super speciality hospitals in Delhi.
The latest initiative of the government is of providing healthcare for the urban poor under the Mukhyamantri Slum Swasthya Yojna scheme, which envisages 120 well-equipped Mobile Medical Units reaching urban slums benefiting over 1 lakh people. This is what the government’s own press release states adding that, with Professionals, specialist doctors providing free consultation, diagnostic services, and medicines. The state government has also simultaneously launched an all-women special mobile medical facility ‘Dai-Didi clinic’ in the urban slums for providing primary health care facilities besides the treatment and diagnosis of diseases related to women’s health and well-being.
Jan Swasthya Sahyog, an integral part of health care in rural Chhattisgarh, is a community-based health programme that was founded in 1996 by a group of postgraduate students at the All India Institute of Medical Sciences in Delhi.
Among the efforts made by the government to make health care more accessible to working class, includes changing OPD timings in government health centres to remain open in the evenings as well. From January 2020 onwards OPD timings were changed to 9 am-1 pm, and reopen from 4 pm-6 pm in winter and 5 pm-7 pm in summer allowing labourers or office goers to access public health care on any given day without having to miss a day of work.
West Bengal has seen 14.5 lakh cases with more than 16,000 deaths as of June 9.
In 2019-20, West Bengal allocated Rs 9,567 crore to health and family welfare i.e. 4.5% of its total budget, according to a September 2019 report from the Reserve Bank of India. The percentage increased in the 2020-21 budget and it has allocated 5.4% of its expenditure for health almost in consonance with Kerala and Tamil Nadu. In 2019-20, West Bengal’s per capita health expenditure was Rs 988, according to National Health Profile (NHP) 2019, being the second lowest; the lowest being Bihar with per capita health expenditure of Rs. 781.
A report in The Wire stated that as per 2018 data, the doctor population ratio was 1:10,411 whereas the WHO recommends a ratio of 10:10,000. The state, however, seems to do better in the bed to population ratio when compared to other states. West Bengal has a government bed to population ratio of 2.25:1000 while Delhi stands at 1.05:1000. West Bengal outperforms even states like Kerala (1.05 beds per 1000) and Tamil Nadu (1.1 beds per 1000).
West Bengal has outsourced secondary and tertiary care, diagnostics, dialysis of patients, ambulance, catering and laundry services to private partners. West Bengal has implemented a public-private partnership (PPP) model to provide medicine at a very high discount (generic medicine) for all (who have a valid prescription) through fair-price medicine shop.
Hospaccx Healthcare Business Consultancy stated in a 2019 article that West Bengal faces a shortfall of 1257 Primary Health Centers and 193, Community Health Centers and overall a skill gap of about 4.62 lakh less health workforce. A 2018 report in TOI pointed out that there are 923 primary health centres in the state and
Further, 30% of the households incur catastrophic health expenditure and spend more than 40% of their annual income on healthcare.
While Maharashtra has had to battle the highest burden of cases in the country being the third most populous state, it has managed to sail through and has avoided a crisis situation like Delhi or Uttar Pradesh. On the other hand, Chhattisgarh, among the poorer states, with a large chunk of its population in rural areas and also belonging to Adivasi community has a decently managed public health system which has kept it afloat and avoided crisis until now. Even West Bengal has fared relatively well on the similar metric of having avoided a crisis until now. Certainly, many other states can be included in this category, like Punjab or Rajasthan or even Andhra Pradesh and the 3 states discussed above are merely examples to enable us to analyse what it takes for differently placed states to avoid unprecedented crisis despite their own unique obstacles.
*Feature Image: Representational image courtesy Vijay Pandey.
 Chakravarthi I, et al. Corporatisation in the private healthcare sector: Case- study from India, 2019.
 Lahane, Tatyarao; Indian Journal of Ophthalmology: March 2021 – Volume 69 – Issue 3 – p 477-478